M1172 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS M1172: Documentation of Td/Tdap Vaccine Contraindication

HCPCS Level II code M1172 designates documentation of a medical reason for not administering a Td or Tdap vaccine, such as prior anaphylaxis to the vaccine or encephalopathy within seven days of a prior td-containing dose. This administrative code matters nationally because it captures clinical contraindications to routine immunization, supports accurate medical records, and informs payer adjudication of vaccine-related service lines.

Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical purpose and common settings, guidance on where the service is typically documented, and notes on payer coverage patterns. The publication highlights billing and documentation context rather than clinical guidance, and identifies areas where policy updates or payer instructions commonly affect reimbursement and reporting.

The piece helps clinicians, billing staff, and policy analysts understand when M1172 is appropriate to use, what documentation it represents, and how major payers treat documentation of vaccine contraindications. Data not provided in the input—such as specific payer fee schedules, associated ICD-10 codes, or related billing codes—is noted as unavailable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1172HCPCS Level IIvaccine contraindicationTdTdapimmunization documentationoutpatient carebilling and coding

Billing Code Overview

HCPCS Level II code M1172 documents a medical reason for not administering the tetanus-diphtheria (Td) or tetanus-diphtheria-acellular pertussis (Tdap) vaccine. The code is used when a clinician records contraindications such as prior anaphylaxis to a Td or Tdap vaccine or a history of encephalopathy within seven days after a previous dose of a td-containing vaccine.

Service type: Vaccine contraindication documentation / Vaccine administration exception

Typical site of service: Outpatient clinical settings, including primary care offices, pediatric clinics, and immunization clinics where vaccine decisions and documentation occur.

Clinical & Coding Specifications

Clinical Context

A 34-year-old adult presents to a primary care clinic for routine immunizations prior to employment. The provider reviews the patient’s immunization history and documents a prior severe immediate hypersensitivity reaction after a previous tetanus-diphtheria-containing vaccine, consistent with anaphylaxis. The clinician determines that administration of Td or Tdap vaccine is contraindicated and completes a focused medical record entry that documents the specific medical reason(s) for not administering the vaccine (e.g., prior anaphylaxis to Td/Tdap, history of encephalopathy within seven days after a prior dose of a Td-containing vaccine).

The clinical workflow includes: review of immunization history and allergy records, patient interview to confirm reaction details and timing, assessment of risks and benefits, documentation of the contraindication using the billing descriptor M1172, discussion of alternative protective measures (such as wound care guidance or immunoglobulin when indicated), entry of the contraindication into the immunization registry and the problem list, and coding/billing staff assigning M1172 for justification of non-administration of Td/Tdap.

Coding Specifications

HCPCS M1348: Patient Activation Measure Increase, Excellent

HCPCS-M1253-AMBULATORY-PALLIATIVE-CARE-PATIENT-DISAVOWAL

HCPCS M1253: Ambulatory Palliative Care Patient Disavowal

HCPCS-M1261-KIDNEY-WAITLIST-PRIOR-TO-DIALYSIS

HCPCS Level II M1261: Kidney/Kidney-Pancreas Waitlist Prior to Dialysis

HCPCS-M1462-HEAD-IMAGING-CLINICAL-INDICATIONS

HCPCS M1462: Head Imaging for Clinical Indications

HCPCS-M1492-PATIENT-NO-FALL-REPORTED

HCPCS Level II M1492: Patient Did Not Report a Fall

HCPCS-M1353-SUICIDE-SAFETY-PLAN-NOT-COMPLETED

HCPCS Level II M1353: Suicide Safety Plan Not Completed

HCPCS-M1196-INITIAL-ITCH-OR-SYMPTOM-SEVERITY-ASSESSMENT-NRS-VRS

HCPCS Level II M1196: Initial Itch/Symptom Severity Assessment (NRS/VRS/ItchyQuant)

HCPCS-M1317-COUNSELING-CSP-CONNECTION-OPT-OUT

HCPCS M1317: Counseling on Community Service Provider Connection, Patient Opt-Out

HCPCS-LEVEL-II-M1292-FRAILTY-WITH-ADVANCED-ILLNESS-66-PLUS

HCPCS Level II M1292: Frailty with Advanced Illness in Patients 66+

HCPCS-M1155-ANAPHYLAXIS-PNEUMOCOCCAL-VACCINE

HCPCS M1155: Anaphylaxis Due to Pneumococcal Vaccine, Documented

Showing 1–10 of 356

Taxonomy Code	Specialty	Notes
`208000000X`	Family Medicine	Common outpatient clinicians who evaluate immunization contraindications and document refusal/contraindication.
`207Q00000X`	Internal Medicine	Adult primary care providers who assess vaccine histories and document medical contraindications.
`363L00000X`	Emergency Medicine	May document contraindications when acute reactions present or during wound care visits.
`261QM0800X`	Nurse Practitioner	NPs frequently perform vaccine evaluation and documentation in ambulatory settings.
`367A00000X`	Physician Assistant	PAs commonly document vaccine contraindications in clinics and urgent care.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z28.1`	Immunization not carried out because of contraindication	Directly documents that `Td`/`Tdap` vaccine was not administered for medical reasons; pairs with `M1172` documentation.
`T88.1XXA`	Other complications following immunization, initial encounter	Used if a prior adverse event such as anaphylaxis occurred after vaccination and is being documented as the reason for contraindication.
`T78.2XXA`	Anaphylactic shock, initial encounter	Documents prior anaphylaxis to a vaccine substance, a primary reason to withhold `Td`/`Tdap`.
`G92`	Toxic encephalopathy	Used when encephalopathy occurred within seven days after a prior `Td`-containing vaccine and supports contraindication.
`Z91.018`	Allergy to other vaccines and biological substances	Records a documented vaccine allergy relevant to withholding `Td`/`Tdap`.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90471`	Immunization administration (single) by intramuscular, intradermal or subcutaneous injection; one vaccine (same clinician)	Performed when `Td`/`Tdap` is administered; relevant to indicate when vaccine administration did occur instead of using `M1172`.
`90472`	Each additional vaccine (single)	Used when multiple vaccines are given in the same visit; not used when `M1172` documents non-administration.
`99213`	Office or other outpatient visit, established patient, low to moderate complexity	Typical visit code for evaluation and documentation of vaccine contraindication in an established patient.
`99214`	Office or other outpatient visit, established patient, moderate to high complexity	Used when documentation of contraindication requires detailed history, decision-making, and counseling.
`90460`	Immunization administration via any route, first vaccine/toxoid component, counseling by physician or other qualified health care professional; first vaccine	Used for vaccine counseling when performed remotely or as part of preventive services; relevant if counseling occurs but vaccine not given.
`99406`	Smoking and tobacco use cessation counseling visit	Example ancillary preventive counseling code that may be billed during the same visit when applicable; included as commonly performed counseling in primary care workflows.

`22`	Increased procedural services	Use when documentation supports substantially greater time or complexity for counseling and documentation about vaccine contraindication and medical justification.
`23`	Unusual anesthesia	Not typically applicable; rarely used if anesthesia was required for related procedure during the visit.
`52`	Reduced services	Use if the visit provided fewer services than usually required because vaccine administration was not performed.
`53`	Discontinued procedure	Use if vaccine administration was started but discontinued due to an acute reaction or discovery of contraindication.
`54`	Surgical care only	Not typically applicable; rarely used in outpatient immunization context.
`55`	Postoperative management only	Not applicable for this non-surgical service in routine practice.
`56`	Preoperative management only	Not applicable for routine vaccine contraindication documentation.
`62`	Two surgeons	Not applicable for vaccine documentation; included for completeness when multiple clinicians are required.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Not applicable in standard vaccine documentation visits.
`CO`	Worker’s compensation	Use when the visit is related to work-related exposure and the payor is the worker’s compensation carrier.
`CQ`	Service delivered under an oral/enteral feeding program	Not applicable; included from supplied list but rarely relevant.
`QK`	Medical direction of two, three, or four qualified health care professionals	Use if a qualified physician directs other clinicians during the visit in settings requiring direction for billing.
`QX`	Service performed by certified nurse midwife	Use if a certified nurse-midwife documents the contraindication in scope of practice.
`QY`	Medical direction of one qualified health care professional	Use when a supervising physician directs one other qualified practitioner providing the service.

OpenPayer